10 September 2021

Before HM Coroner Peter Nieto
Chesterfield Coroner’s Court
6-9 September 2021

An inquest has found that the death of 23 year old Alasdair Conlon was misadventure, meaning he did not intend to end his life. He died a while on weekend leave as a sectioned mental health patient at Chesterfield Royal Hospital, run by Derbyshire Healthcare NHS Foundation Trust. The inquest jury found that the decision to grant leave made a significant contribution to Alasdair’s death.

Alasdair was found dead in his flat on 9 July 2017. His family describe him as a much loved young man with a keen sense of humour and an infectious laugh. He was a talented musician and performer who enjoyed composing, DJing and attending festivals. He was never happier than by the sea and was an accomplished surfer.

With a history of mental ill health, Alasdair voluntarily went to hospital in September 2015. He was later sectioned from May to November 2016, and finally from April 2017 until his death. There had been multiple varied diagnoses of his conditions in that time. He also had serious anxieties around health, and related issues with drug use.

From Friday 7 July 2017, Alasdair was granted weekend leave from hospital (known as section 17 leave) and was due to return at 1pm on 9 July 2017. His usual doctor had been on sick leave, and a locum consultant psychiatrist was responsible for the decision to permit leave.

This decision had followed one of the regular inpatient care meetings (known as PIPA), which the inquest heard were restrictive and allowed little opportunity for in-depth discussion. The psychiatrist said Alasdair himself had applied considerable “pressure” to be granted leave.

The in-reach team confirmed their availability to provide support over the weekend, so the leave was granted on this condition. They were to visit Alasdair at his flat on the Saturday morning. However, they were unable to contact Alasdair, and subsequently failed to make the visit.

The in-reach team were then due to phone Alasdair later the Saturday evening, but it did not appear this call was ever made. Further in person attempts to engage were made on Sunday 9 July, but he did not answer the door and the team did not feel it appropriate to try the door handle. This information was passed on to the ward nurse.

Alasdair’s family were then contacted by the hospital and asked if they knew where he was. This was the first they had heard about him being granted leave. The psychiatrist who granted it told the inquest he had not reviewed the leave documentation or contacted the family, as he assumed this would have been done by nursing staff.

The hospital believed Alasdair was “low risk” and would return. When his family contacted them later that day he still had not returned. Alasdair’s father then went to his flat and sadly found him dead. It was not possible for experts to determine the time and date of his death. Evidence was heard that Alasdair was ‘naïve' to the effects of the substances he had ingested, which may have been the reason he took the amount he did.

There had been a plan for Alasdair to possibly be moved into supported accommodation, to receive continued support in the community. The hospital had scheduled a meeting for 11 July 2017, in advance of Alasdair’s upcoming discharge, but his family had only been informed on the day that he was later found dead.

An inquest jury concluded that his death was misadventure, caused by mixed drug toxicity. In a narrative conclusion, they also found that:

  • The decision to implement leave was “not appropriate or correct”.
  • Leave planning was rushed, with little or no review of relevant documents.
  • As such, the decision to grant leave made a significant contribution to Alasdair’s death.

Alasdair’s parents, Jennifer and Martin Conlon, said: “Alasdair and our family were badly let down by Derbyshire NHS foundation trust. He did not receive the care that he deserved and the confusion over his care plan led to leave being granted, which was inappropriate for someone as vulnerable as Alasdair. This, together with lack of communication between the health authority and his family put Alasdair in an unsafe position. We are keen that, in the light of what happened to Alasdair, procedures and protocols change so that no-one else is put in this position.”                                                          

Lucy McKay, spokesperson for the charity INQUEST who supported the family, said: “The value of the input of family members in the care of mental health patients is well known, yet it is still forgotten or overlooked far too often. It is clear Alasdair’s family were strong advocates for his care. They have been badly failed by Derbyshire Healthcare NHS Foundation Trust. We hope the Trust will now take action on the issues exposed by this inquest, and that mental health hospitals nationally will critically consider their own practices.”

Neil Cronin of Southerns Solicitors, who represent the family, said: “Four years on from Alasdair’s passing, a conclusion had finally been reached regarding the circumstances.

Overarching themes throughout have been in relation to communication, or a lack thereof, and diversion from Trust policy when record keeping, risk assessing and implementing protective factors for the issue of section 17 leave. The merit of familial involvement continues to be firmly foregrounded as an additional layer of support for vulnerable persons.

The family hope that the Trust will heed the findings of this inquest, namely those made in relation to determining the appropriateness of granting leave, and seek to ensure that identified failures are mitigated within the future.”


For further information and photos please contact Lucy McKay on 020 7263 1111 or [email protected]

The family are represented by INQUEST Lawyers Group members Neil Cronin of Southerns Solicitors and Simon Murray of St John’s Buildings Chambers. They are supported by INQUEST caseworker Caroline Finney.

Other Interested persons represented were Derbyshire Healthcare NHS Foundation Trust.                                                 

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.